Publications by authors named "Robert Cronin"

57 Publications

Digital behavioural interventions for people with sickle cell disease.

Cochrane Libr 2021 27;2021(4). Epub 2021 Apr 27.

Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington, USA.

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To identify and assess the effects of digital behavioural interventions focused on behavioural change in people with SCD on: medication adherence or disease management (such as managing acute and chronic pain), or both, on health- and other-related outcomes;specific subgroups defined by age (i.e. children, adolescents and adults) and type of modality or delivery (e.g. cell phone, the Internet).
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http://dx.doi.org/10.1002/14651858.CD014669DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8078570PMC
April 2021

Parent Activation in the Neonatal Intensive Care Unit.

Am J Perinatol 2021 Oct 12. Epub 2021 Oct 12.

Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee.

Objective:  Patient activation is the knowledge, skills, and confidence to manage one's health; parent activation is a comparable concept related to a parent's ability to manage a child's health. Activation in adults is a modifiable risk factor and associated with clinical outcomes and health care utilization. We examined activation in parents of hospitalized newborns observing temporal trends and associations with sociodemographic characteristics, neonate characteristics, and outcomes.

Study Design:  Participants included adult parents of neonates admitted to a level-IV neonatal intensive care unit in an academic medical center. Activation was measured with the 10-item Parent version of the Patient Activation Measure (P-PAM) at admission, discharge, and 30 days after discharge. Associations with sociodemographic variables, health literacy, clinical variables, and health care utilization were evaluated.

Results:  A total of 96 adults of 64 neonates were enrolled. The overall mean P-PAM score on admission was 81.8 (standard deviation [SD] = 18), 88.8 (SD = 13) at discharge, and 86.8 (SD = 16) at 30-day follow-up. Using linear mixed regression model, P-PAM score was significantly associated with timing of measurement. Higher P-PAM scores were associated with higher health literacy ( = 0.002) and higher in mothers compared to fathers ( = 0.040). There were no significant associations of admission P-PAM scores with sociodemographic characteristics. Parents of neonates who had a surgical diagnosis had a statistically significant ( = 0.003) lower score than those who did not. There were no associations between discharge P-PAM scores and neonates' lengths of stay or other indicators of illness severity.

Conclusion:  Parental activation in the NICU setting was higher than reported in the adult and limited pediatric literature; scores increased from admission to discharge and 30-day postdischarge. Activation was higher in mothers and parents with higher health literacy. Additional larger scale studies are needed to determine whether parental activation is associated with long-term health care outcomes as seen in adults.

Key Points: · Little is known about activation in parents of neonates.. · Activation plays a role in health outcomes in adults.. · Larger studies are needed to explore parent activation..
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http://dx.doi.org/10.1055/s-0041-1736294DOI Listing
October 2021

Economic Evaluation of Regular Transfusions for Cerebral Infarct Recurrence in the Silent Cerebral Infarct Transfusion Trial.

Blood Adv 2021 Oct 4. Epub 2021 Oct 4.

The Ohio State University, Columbus, Ohio, United States.

In 2020, the American Society of Hematology published evidence-based guidelines for cerebrovascular disease in individuals with sickle cell anemia (SCA). While guidelines were based on NIH-sponsored randomized controlled trials, no cost-effectiveness analysis was completed for children with SCA and silent cerebral infarcts. We conducted a cost-effectiveness analysis comparing regular blood transfusion versus standard care using Silent Cerebral Infarct Transfusion (SIT) Trial participants. This analysis included a modified societal perspective with direct costs (hospitalization, emergency room visit, transfusion, outpatient care, iron chelation) and indirect costs (special education). Direct medical costs were estimated from hospitalizations from SIT hospitals and unlinked aggregated hospital and outpatient costs from SIT sites using the Pediatric Health Information System. Indirect costs were estimated from published literature. Effectiveness was prevention of infarct recurrence. Incremental cost-effectiveness ratio using a 3-year time horizon (mean SIT trial participant follow-up) compared transfusion versus standard care. A total of 196 participants received transfusions (N=90) or standard care (N=106), with a mean age of 10.0 years. Annual hospitalization costs were reduced by 54% for transfusions than standard care ($4,929 vs. $10,802), but transfusion group outpatient costs added $22,454 to $137,022 per year. Special education costs savings was $2,634 over three years for every infarct prevented. Transfusion therapy had an incremental cost-effectiveness ratio of $22,025 per infarct prevented. Children with pre-existing silent cerebral infarcts receiving blood transfusions have lower hospitalization but higher outpatient costs, primarily associated with oral iron chelator deferasirox. Regular blood transfusion therapy is cost-effective for infarct recurrence in children with SCA. This trial is registered at www.clinicaltrials.gov as NCT00072761.
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http://dx.doi.org/10.1182/bloodadvances.2021004864DOI Listing
October 2021

Comparison of family health history in surveys vs electronic health record data mapped to the observational medical outcomes partnership data model in the All of Us Research Program.

J Am Med Inform Assoc 2021 03;28(4):695-703

Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Objective: Family health history is important to clinical care and precision medicine. Prior studies show gaps in data collected from patient surveys and electronic health records (EHRs). The All of Us Research Program collects family history from participants via surveys and EHRs. This Demonstration Project aims to evaluate availability of family health history information within the publicly available data from All of Us and to characterize the data from both sources.

Materials And Methods: Surveys were completed by participants on an electronic portal. EHR data was mapped to the Observational Medical Outcomes Partnership data model. We used descriptive statistics to perform exploratory analysis of the data, including evaluating a list of medically actionable genetic disorders. We performed a subanalysis on participants who had both survey and EHR data.

Results: There were 54 872 participants with family history data. Of those, 26% had EHR data only, 63% had survey only, and 10.5% had data from both sources. There were 35 217 participants with reported family history of a medically actionable genetic disorder (9% from EHR only, 89% from surveys, and 2% from both). In the subanalysis, we found inconsistencies between the surveys and EHRs. More details came from surveys. When both mentioned a similar disease, the source of truth was unclear.

Conclusions: Compiling data from both surveys and EHR can provide a more comprehensive source for family health history, but informatics challenges and opportunities exist. Access to more complete understanding of a person's family health history may provide opportunities for precision medicine.
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http://dx.doi.org/10.1093/jamia/ocaa315DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7973437PMC
March 2021

Diversity and inclusion for the All of Us research program: A scoping review.

PLoS One 2020 1;15(7):e0234962. Epub 2020 Jul 1.

National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, Maryland, United States of America.

The All of Us Research Program (All of Us) is a national effort to accelerate health research by exploring the relationship between lifestyle, environment, and genetics. It is set to become one of the largest research efforts in U.S. history, aiming to build a national resource of data from at least one million participants. All of Us aims to address the need for more diversity in research and set the stage for that diversity to be leveraged in precision medicine research to come. This paper describes how the program assessed demographic characteristics of participants who have enrolled in other U.S. biomedical research cohorts to better understand which groups are traditionally represented or underrepresented in biomedical research. We 1) reviewed the enrollment characteristics of national cohort studies like All of Us, and 2) surveyed the literature, focusing on key diversity categories essential to the program's enrollment aims. Based on these efforts, All of Us emphasizes enrollment of racial and ethnic minorities, and has formally designated the following additional groups as historically underrepresented: individuals-with inadequate access to medical care; under the age of 18 or over 65; with an annual household income at or below 200% of the federal poverty level; who have a cognitive or physical disability; have less than a high school education or equivalent; are intersex; identify as a sexual or gender minority; or live in rural or non-metropolitan areas. Research accounting for wider demographic variability is critical. Only by ensuring diversity and by addressing the very barriers that limit it, can we position All of Us to better understand and tackle health disparities.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0234962PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7329113PMC
September 2020

Association between hospital admissions and healthcare provider communication for individuals with sickle cell disease.

Hematology 2020 Dec;25(1):229-240

Department of Hematology/Oncology, UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA.

To test the hypothesis that caregivers' or adult participants' low ratings of provider communication are associated with more hospital admissions among adults and children with sickle cell disease (SCD), respectively. Secondarily, we determined whether there was an association between the caregivers' or participants' health literacy and rating of providers' communication. Primary data were collected from participants through surveys between 2014 and 2016, across six sickle cell centers throughout the U.S. In this cross-sectional cohort study, 211 adults with SCD and 331 caregivers of children with SCD completed surveys evaluating provider communication using the Consumer Assessment of Healthcare Providers and Systems (CAHPS), healthcare utilization, health literacy, and other sociodemographic and behavioral variables. Analyses included descriptive statistics, bivariate analyses, and logistic regression. Participants with better ratings of provider communication were less likely to be hospitalized (odds ratio (OR) = 0.54, 95% confidence interval (CI) = [0.35, 0.83]). Positive ratings of provider communication were associated with fewer readmissions for children (OR = 0.23, 95% CI = [0.09, 0.57]). Participants with better ratings of provider communication were less likely to rate their health literacy as lower (regression coefficient (B) = -0.28, 95% CI = [-0.46, -0.10]). Low ratings of provider communication were associated with more hospitalizations and readmissions in SCD, suggesting the need for interventions targeted at improving patient-provider communication which could decrease hospitalizations for this population.
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http://dx.doi.org/10.1080/16078454.2020.1780737DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7440685PMC
December 2020

Engaging Individuals with Sickle Cell Disease in Patient-Centered Outcomes Research: A Community Health Ambassador Training Model.

J Health Care Poor Underserved 2020 ;31(1):353-369

Developing innovative strategies to engage patients as research partners is a priority in efforts to reduce health disparities in underserved communities. We describe the development and implementation of a training model to prepare Community Health Ambassadors (CHAs) to serve as liaisons to engage individuals with sickle cell disease (SCD) in patient-centered outcomes research. We trained CHAs on research guidelines, human subjects' protection, and SCD self-management. Community Health Ambassadors then employed community-level strategies to engage individuals with SCD and their families (N=432) residing in rural and urban communities throughout Tennessee. By engaging the SCD community, CHAs identified areas of burden for self-management and patientpreferred strategies to engage members of underserved minority groups in research. This community-based training model, which places CHAs as liaisons between researchers and the community, holds promise for scaling-up for replication and implementation in studies seeking to engage underserved populations with a chronic disease in health research.
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http://dx.doi.org/10.1353/hpu.2020.0027DOI Listing
May 2021

Development of the Initial Surveys for the All of Us Research Program.

Epidemiology 2019 07;30(4):597-608

Cardiology Section, Department of Medicine, Veterans Affairs Boston Healthcare System, Boston, MA.

Background: The All of Us Research Program is building a national longitudinal cohort and collecting data from multiple information sources (e.g., biospecimens, electronic health records, and mobile/wearable technologies) to advance precision medicine. Participant-provided information, collected via surveys, will complement and augment these information sources. We report the process used to develop and refine the initial three surveys for this program.

Methods: The All of Us survey development process included: (1) prioritization of domains for scientific needs, (2) examination of existing validated instruments, (3) content creation, (4) evaluation and refinement via cognitive interviews and online testing, (5) content review by key stakeholders, and (6) launch in the All of Us electronic participant portal. All content was translated into Spanish.

Results: We conducted cognitive interviews in English and Spanish with 169 participants, and 573 individuals completed online testing. Feedback led to over 40 item content changes. Lessons learned included: (1) validated survey instruments performed well in diverse populations reflective of All of Us; (2) parallel evaluation of multiple languages can ensure optimal survey deployment; (3) recruitment challenges in diverse populations required multiple strategies; and (4) key stakeholders improved integration of surveys into larger Program context.

Conclusions: This efficient, iterative process led to successful testing, refinement, and launch of three All of Us surveys. Reuse of All of Us surveys, available at http://researchallofus.org, may facilitate large consortia targeting diverse populations in English and Spanish to capture participant-provided information to supplement other data, such as genetic, physical measurements, or data from electronic health records.
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http://dx.doi.org/10.1097/EDE.0000000000001028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6548672PMC
July 2019

Development of a Technology-Supported, Lay Peer-to-Peer Family Engagement Consultation Service in a Pediatric Hospital.

AMIA Annu Symp Proc 2018 5;2018:730-739. Epub 2018 Dec 5.

Vanderbilt University Medical Center, Nashville, Tennessee.

Patient and caregiver engagement in making decisions and taking actions to promote health are critically important for improving outcomes, enhancing healthcare experience satisfaction, and reducing costs. Patients and caregivers have a wealth of expertise in illness self-management and can aid others in attaining high levels of activation through peer-to-peer social support. We describe the development of a technology-supported, family engagement consultation service at Children's of Alabama that integrates parent volunteers as front-line, peer-to-peer support consultants with a multidisciplinary team of informatics professionals in the pediatric hospital setting. This service was adapted from an existing engagement consultation service with a traditional medical consultation model at Vanderbilt Children's Hospital. The unique features of the new model are articulated, along with plans for a shared knowledge database of consumer health resources to meet needs. The layperson peer-to-peer design is highly innovative and relevant as healthcare transitions towards increasingly participatory and personalized medicine.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6371240PMC
November 2019

Risk factors for hospitalizations and readmissions among individuals with sickle cell disease: results of a U.S. survey study.

Hematology 2019 Dec;24(1):189-198

k Department of Hematology/Oncology , UCSF Benioff Children's Hospital Oakland , Oakland , CA , USA.

Objective: Hospital admissions are significant events in the care of individuals with sickle cell disease (SCD) due to associated costs and potential for quality of life compromise.

Methods: This cross-sectional cohort study evaluated risk factors for admissions and readmissions between October 2014 and March 2016 in adults with SCD (n = 201) and caregivers of children with SCD (n = 330) at six centres across the U.S. Survey items assessed social determinants of health (e.g. educational attainment, difficulty paying bills), depressive symptoms, social support, health literacy, spirituality, missed clinic appointments, and outcomes hospital admissions and 30-day readmissions in the previous year.

Results: A majority of adults (64%) and almost half of children (reported by caregivers: 43%) were admitted, and fewer readmitted (adults: 28%; children: 9%). The most common reason for hospitalization was uncontrolled pain (admission: adults: 84%, children: 69%; readmissions: adults: 83%, children: 69%). Children were less likely to have admissions/readmissions than adults (Admissions: OR: 0.35, 95% CI: [0.23,0.52]); Readmissions: 0.23 [0.13,0.41]). For all participants, missing appointments were associated with admissions (1.66 [1.07, 2.58]) and readmissions (2.68 [1.28, 6.29]), as were depressive symptoms (admissions: 1.36 [1.16,1.59]; readmissions: 1.24 [1.04, 1.49]). In adults, difficulty paying bills was associated with more admissions, (3.11 [1.47,6.62]) readmissions (3.7 [1.76,7.79]), and higher spirituality was associated with fewer readmissions (0.39 [0.18,0.81]).

Discussion: Missing appointments was significantly associated with admissions and readmissions. Findings confirm that age, mental health, financial insecurity, spirituality, and clinic attendance are all modifiable factors that are associated with admissions and readmissions; addressing them could reduce hospitalizations.
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http://dx.doi.org/10.1080/16078454.2018.1549801DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6349225PMC
December 2019

Increased Patient Activation Is Associated with Fewer Emergency Room Visits and Hospitalizations for Pain in Adults with Sickle Cell Disease.

Pain Med 2019 08;20(8):1464-1471

Division of Hematology/Oncology, Department of Pediatrics, Vanderbilt-Meharry Center for Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Objective: Recurrent vaso-occlusive pain episodes, the most common complication of sickle cell disease (SCD), cause frequent health care utilization. Studies exploring associations between patient activation and acute health care utilization for pain are lacking. We tested the hypothesis that increased activation and self-efficacy are associated with decreased health care utilization for pain in SCD.

Methods: In this cross-sectional study of adults with SCD at a tertiary medical center, we collected demographics, SCD phenotype, Patient Activation Measure levels, and self-efficacy scores using structured questionnaires. We reviewed charts to obtain disease-modifying therapy and acute health care utilization, defined as emergency room visits and hospitalizations, for vaso-occlusive pain episodes. Negative binomial regression analyses were used to test the hypothesis.

Results: We surveyed 67 adults with SCD. The median age was 27.0 years, 53.7% were female, and 95.5% were African American. Median health care utilization for pain over one year (range) was 2.0 (0-24). Only one-third of participants (38.8%) were at the highest activation level (median [range] = 3 [1-4]). Two-thirds (65.7%) of participants had high self-efficacy (median [range] = 32.0 [13-45]). Regressions showed significant association between health care utilization and activation (incidence rate ratio [IRR] = 0.663, P = 0.045), self-efficacy (IRR = 0.947, P = 0.038), and male sex (IRR = 0.390, P = 0.003). Two outliers with high activation, self-efficacy, and health care utilization also had addictive behavior.

Conclusions: Many individuals with SCD have suboptimal activation and reduced self-efficacy. Higher activation and self-efficacy were associated with lower health care utilization for pain. Additional studies are needed to evaluate interventions to improve activation and self-efficacy and reduce acute health care utilization for pain.
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http://dx.doi.org/10.1093/pm/pny194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6686119PMC
August 2019

Patient and healthcare provider views on a patient-reported outcomes portal.

J Am Med Inform Assoc 2018 11;25(11):1470-1480

Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.

Background: Over the past decade, public interest in managing health-related information for personal understanding and self-improvement has rapidly expanded. This study explored aspects of how patient-provided health information could be obtained through an electronic portal and presented to inform and engage patients while also providing information for healthcare providers.

Methods: We invited participants using ResearchMatch from 2 cohorts: (1) self-reported healthy volunteers (no medical conditions) and (2) individuals with a self-reported diagnosis of anxiety and/or depression. Participants used a secure web application (dashboard) to complete the PROMIS® domain survey(s) and then complete a feedback survey. A community engagement studio with 5 healthcare providers assessed perspectives on the feasibility and features of a portal to collect and display patient provided health information. We used bivariate analyses and regression analyses to determine differences between cohorts.

Results: A total of 480 participants completed the study (239 healthy, 241 anxiety and/or depression). While participants from the tw2o cohorts had significantly different PROMIS scores (p < .05), both cohorts welcomed the concept of a patient-centric dashboard, saw value in sharing results with their healthcare provider, and wanted to view results over time. However, factors needing consideration before widespread use included personalization for the patient and their health issues, integration with existing information (eg electronic health records), and integration into clinician workflow.

Conclusions: Our findings demonstrated a strong desire among healthy people, patients with chronic diseases, and healthcare providers for a self-assessment portal that can collect patient-reported outcome metrics and deliver personalized feedback.
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http://dx.doi.org/10.1093/jamia/ocy111DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6213079PMC
November 2018

Common Consumer Health-Related Needs in the Pediatric Hospital Setting: Lessons from an Engagement Consultation Service.

Appl Clin Inform 2018 07 8;9(3):595-603. Epub 2018 Aug 8.

Department of Biomedical Informatics, Vanderbilt University Medical Center, Vanderbilt University, Nashville, Tennessee, United States.

Background: Informed and engaged parents may influence outcomes for childhood illness. Understanding the needs of the caregivers of pediatric patients is a critical first step in promoting engagement in their child's care. In 2014, we developed an Engagement Consultation Service at the Monroe Carell Jr. Children's Hospital at Vanderbilt. This service determines the health-related needs of the caregivers of hospitalized children and makes educational or technology recommendations to meet those needs and support engagement.

Objectives: This report describes the most common health-related needs identified in the caregivers of hospitalized pediatric patients and details the recommended interventions to meet those needs.

Methods: The most commonly reported consumer health-related needs from our 3-year experience with the Engagement Consultation Service were extracted from consultations notes. Each need was classified by semantic type using a taxonomy of consumer health needs. Typical recommendations for each need and their administration were detailed.

Results: The most frequently recognized needs involved communicating with health care providers after discharge, using medical devices, distinguishing between benign and concerning symptoms, knowing what questions to ask providers and remembering them, finding trustworthy sources of information online, understanding disease prognosis, and getting emotional support. A variety of apps, Web sites, printed materials, and online groups were recommended.

Conclusion: The parents of hospitalized patients share several common health-related needs that can be addressed with educational and technology interventions. An inpatient Engagement Consultation Service provides a generalizable framework for identifying health-related needs and delivers tools to meet those needs and promote engagement during and after hospitalizations.
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http://dx.doi.org/10.1055/s-0038-1667205DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6082659PMC
July 2018

Patient-Centered eHealth Interventions for Children, Adolescents, and Adults With Sickle Cell Disease: Systematic Review.

J Med Internet Res 2018 07 19;20(7):e10940. Epub 2018 Jul 19.

Division of Hematology, Duke University School of Medicine, Durham, NC, United States.

Background: Sickle cell disease is an inherited blood disorder that affects over 100,000 Americans. Sickle cell disease-related complications lead to significant morbidity and early death. Evidence supporting the feasibility, acceptability, and efficacy of self-management electronic health (eHealth) interventions in chronic diseases is growing; however, the evidence is unclear in sickle cell disease.

Objective: We systematically evaluated the most recent evidence in the literature to (1) review the different types of technological tools used for self-management of sickle cell disease, (2) discover and describe what self-management activities these tools were used for, and (3) assess the efficacy of these technologies in self-management.

Methods: We reviewed literature published between 1995 and 2016 with no language limits. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and other sources. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two independent reviewers screened titles and abstracts, assessed full-text articles, and extracted data from articles that met inclusion criteria. Eligible studies were original research articles that included texting, mobile phone-based apps, or other eHealth interventions designed to improve self-management in pediatric and adult patients with sickle cell disease.

Results: Of 1680 citations, 16 articles met all predefined criteria with a total of 747 study participants. Interventions were text messaging (4/16, 25%), native mobile apps (3/16, 19%), Web-based apps (5/16, 31%), mobile directly observed therapy (2/16, 13%), internet-delivered cognitive behavioral therapy (2/16, 13%), electronic pill bottle (1/16, 6%), or interactive gamification (2/16, 13%). Interventions targeted monitoring or improvement of medication adherence (5/16, 31%); self-management, pain reporting, and symptom reporting (7/16, 44%); stress, coping, sleep, and daily activities reporting (4/16, 25%); cognitive training for memory (1/16, 6%); sickle cell disease and reproductive health knowledge (5/16, 31%); cognitive behavioral therapy (2/16, 13%); and guided relaxation interventions (1/16, 6%). Most studies (11/16, 69%) included older children or adolescents (mean or median age 10-17 years; 11/16, 69%) and 5 included young adults (≥18 years old) (5/16, 31%). Sample size ranged from 11 to 236, with a median of 21 per study: <20 in 6 (38%), ≥20 to <50 in 6 (38%), and >50 participants in 4 studies (25%). Most reported improvement in self-management-related outcomes (15/16, 94%), as well as high satisfaction and acceptability of different study interventions (10/16, 63%).

Conclusions: Our systematic review identified eHealth interventions measuring a variety of outcomes, which showed improvement in multiple components of self-management of sickle cell disease. Despite the promising feasibility and acceptability of eHealth interventions in improving self-management of sickle cell disease, the evidence overall is modest. Future eHealth intervention studies are needed to evaluate their efficacy, effectiveness, and cost effectiveness in promoting self-management in patients with sickle cell disease using rigorous methods and theoretical frameworks with clearly defined clinical outcomes.
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http://dx.doi.org/10.2196/10940DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6072976PMC
July 2018

Adapting medical guidelines to be patient-centered using a patient-driven process for individuals with sickle cell disease and their caregivers.

BMC Hematol 2018 8;18:12. Epub 2018 Jun 8.

5Department of Pediatrics, Division of Hematology/Oncology, Vanderbilt-Meharry Center for Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN USA.

Background: Evidence-based guidelines for sickle cell disease (SCD) health maintenance and management have been developed for primary health care providers, but not for individuals with SCD. To improve the quality of care delivered to individuals with SCD and their caregivers, the main purposes of this study were to: (1) understand the desire for patient-centered guidelines among the SCD community; and (2) adapt guideline material to be patient-centered using community-engagement strategies involving health care providers, community -based organizations, and individuals with the disease.

Methods: From May-December 2016, a volunteer sample of 107 individuals with SCD and their caregivers gave feedback at community forums ( = 64) and community listening sessions ( = 43) about technology use for health information and desire for SCD-related guidelines. A team of community research partners consisting of community stakeholders, individuals living with SCD, and providers and researchers (experts) in SCD at nine institutions adapted guidelines to be patient-centered based on the following criteria: (1) understandable, (2) actionable, and (3) useful.

Results: In community forums (n = 64), almost all participants (91%) wanted direct access to the content of the guidelines. Participants wanted guidelines in more than one format including paper (73%) and mobile devices (79%). Guidelines were adapted to be patient-centered. After multiple iterations of feedback, 100% of participants said the guidelines were understandable, most (88%) said they were actionable, and everyone (100%) would use these adapted guidelines to discuss their medical care with their health care providers.

Conclusions: Individuals with SCD and their caregivers want access to guidelines through multiple channels, including technology. Guidelines written for health care providers can be adapted to be patient-centered using Community-engaged research involving providers and patients. These patient-centered guidelines provide a framework for patients to discuss their medical care with their health care providers.
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http://dx.doi.org/10.1186/s12878-018-0106-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5994026PMC
June 2018

Technology use and preferences to support clinical practice guideline awareness and adherence in individuals with sickle cell disease.

J Am Med Inform Assoc 2018 08;25(8):976-988

Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.

Objective: Sickle cell disease (SCD) is a chronic condition affecting over 100 000 individuals in the United States, predominantly from vulnerable populations. Clinical practice guidelines, written for providers, have low adherence. This study explored knowledge about guidelines; desire for guidelines; and how technology could support guideline awareness and adherence, examining current technology uses, and user preferences to inform design of a patient-centered guidelines application in a chronic disease.

Methods: This cross-sectional mixed-methods study involved semi-structured interviews, surveys, and focus groups of adolescents and adults with SCD. We evaluated interest, preferences, and anticipated benefits or barriers of a patient-centered adaptation of SCD practice guidelines; prospective technology uses for health; and barriers to technology utilization.

Results: Forty-seven individuals completed surveys and interviews, and 39 participated in three separate focus groups. Most participants (91%) were unaware of SCD guidelines, but almost all (96%) expressed interest in a guidelines application, identifying benefits (knowledge, activation, individualization, and rewards), and barriers (poor information, low motivation, and resource limitations). Current technology health uses included information access, care coordination, and reminders about health-related actions. Prospective technology uses included informational messaging and timely alerts. Barriers to technology use included lack of interest, lack of utility, and preference for direct communication.

Conclusions: This study's findings can inform the design of clinical practice guideline applications, suggesting a promising role for technology to engage patients, facilitate care decisions and actions, and improve outcomes.
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http://dx.doi.org/10.1093/jamia/ocy036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6077809PMC
August 2018

Modifying factors of the health belief model associated with missed clinic appointments among individuals with sickle cell disease.

Hematology 2018 Oct 29;23(9):683-691. Epub 2018 Mar 29.

k Department of Hematology/Oncology , UCSF Benioff Children's Hospital Oakland , Oakland , CA , USA.

Objectives: Outpatient care is critical in the management of chronic diseases, including sickle cell disease (SCD). Risk factors for poor adherence with clinic appointments in SCD are poorly defined. This exploratory study evaluated associations between modifying variables from the Health Belief Model and missed appointments.

Methods: We surveyed adults with SCD (n = 211) and caregivers of children with SCD (n = 331) between October 2014 and March 2016 in six centres across the U.S. The survey tool utilized the framework of the Health Belief Model, and included: social determinants, psychosocial variables, social support, health literacy and spirituality.

Results: A majority of adults (87%) and caregivers of children (65%) reported they missed a clinic appointment. Children (as reported by caregivers) were less likely to miss appointments than adults (OR:0.22; 95% CI:(0.13,0.39)). In adults, financial insecurity (OR:4.49; 95% CI:(1.20, 20.7)), health literacy (OR:4.64; 95% CI:(1.33, 16.15)), and age (OR:0.95; 95% CI:(0.91,0.99)) were significantly associated with missed appointments. In all participants, lower spirituality was associated with missed appointments (OR:1.83; 95%CI:(1.13, 2.94)). The most common reason for missing an appointment was forgetfulness (adults: 31%, children: 26%). A majority thought reminders would help (adults: 83%, children: 71%) using phone calls (adults: 62%, children: 61%) or text messages (adults: 56%, children: 51%).

Conclusions: Our findings demonstrate that modifying components of the Health Belief Model, including age, financial security, health literacy, spirituality, and lacking cues to action like reminders, are important in missed appointments and addressing these factors could improve appointment-keeping for adults and children with SCD.
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http://dx.doi.org/10.1080/10245332.2018.1457200DOI Listing
October 2018

Mining 100 million notes to find homelessness and adverse childhood experiences: 2 case studies of rare and severe social determinants of health in electronic health records.

J Am Med Inform Assoc 2018 01;25(1):61-71

Department of Biomedical Informatics.

Objective: Understanding how to identify the social determinants of health from electronic health records (EHRs) could provide important insights to understand health or disease outcomes. We developed a methodology to capture 2 rare and severe social determinants of health, homelessness and adverse childhood experiences (ACEs), from a large EHR repository.

Materials And Methods: We first constructed lexicons to capture homelessness and ACE phenotypic profiles. We employed word2vec and lexical associations to mine homelessness-related words. Next, using relevance feedback, we refined the 2 profiles with iterative searches over 100 million notes from the Vanderbilt EHR. Seven assessors manually reviewed the top-ranked results of 2544 patient visits relevant for homelessness and 1000 patients relevant for ACE.

Results: word2vec yielded better performance (area under the precision-recall curve [AUPRC] of 0.94) than lexical associations (AUPRC = 0.83) for extracting homelessness-related words. A comparative study of searches for the 2 phenotypes revealed a higher performance achieved for homelessness (AUPRC = 0.95) than ACE (AUPRC = 0.79). A temporal analysis of the homeless population showed that the majority experienced chronic homelessness. Most ACE patients suffered sexual (70%) and/or physical (50.6%) abuse, with the top-ranked abuser keywords being "father" (21.8%) and "mother" (15.4%). Top prevalent associated conditions for homeless patients were lack of housing (62.8%) and tobacco use disorder (61.5%), while for ACE patients it was mental disorders (36.6%-47.6%).

Conclusion: We provide an efficient solution for mining homelessness and ACE information from EHRs, which can facilitate large clinical and genetic studies of these social determinants of health.
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http://dx.doi.org/10.1093/jamia/ocx059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6080810PMC
January 2018

A technology-based patient and family engagement consult service for the pediatric hospital setting.

J Am Med Inform Assoc 2018 02;25(2):167-174

Department of Biomedical Informatics, VUMC, Nashville, TN, USA.

Objective: The Vanderbilt Children's Hospital launched an innovative Technology-Based Patient and Family Engagement Consult Service in 2014. This paper describes our initial experience with this service, characterizes health-related needs of families of hospitalized children, and details the technologies recommended to promote engagement and meet needs.

Materials And Methods: We retrospectively reviewed consult service documentation for patient characteristics, health-related needs, and consultation team recommendations. Needs were categorized using a consumer health needs taxonomy. Recommendations were classified by technology type.

Results: Twenty-two consultations were conducted with families of patients ranging in age from newborn to 15 years, most with new diagnoses or chronic illnesses. The consultation team identified 99 health-related needs (4.5 per consultation) and made 166 recommendations (7.5 per consultation, 1.7 per need). Need categories included 38 informational needs, 26 medical needs, 23 logistical needs, and 12 social needs. The most common recommendations were websites (50, 30%) and mobile applications (30, 18%). The most frequent recommendations by need category were websites for informational needs (39, 50%), mobile applications for medical needs (15, 40%), patient portals for logistical needs (12, 44%), and disease-specific support groups for social needs (19, 56%).

Discussion: Families of hospitalized pediatric patients have a variety of health-related needs, many of which could be addressed by technology recommendations from an engagement consult service.

Conclusion: This service is the first of its kind, offering a potentially generalizable and scalable approach to assessing health-related needs, meeting them with technologies, and promoting patient and family engagement in the inpatient setting.
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http://dx.doi.org/10.1093/jamia/ocx067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6080811PMC
February 2018

Classifying patient portal messages using Convolutional Neural Networks.

J Biomed Inform 2017 10 30;74:59-70. Epub 2017 Aug 30.

Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Computer Science and Engineering, Vanderbilt University, Nashville, TN, USA.

Objective: Patients communicate with healthcare providers via secure messaging in patient portals. As patient portal adoption increases, growing messaging volumes may overwhelm providers. Prior research has demonstrated promise in automating classification of patient portal messages into communication types to support message triage or answering. This paper examines if using semantic features and word context improves portal message classification.

Materials And Methods: Portal messages were classified into the following categories: informational, medical, social, and logistical. We constructed features from portal messages including bag of words, bag of phrases, graph representations, and word embeddings. We trained one-versus-all random forest and logistic regression classifiers, and convolutional neural network (CNN) with a softmax output. We evaluated each classifier's performance using Area Under the Curve (AUC).

Results: Representing the messages using bag of words, the random forest detected informational, medical, social, and logistical communications in patient portal messages with AUCs: 0.803, 0.884, 0.828, and 0.928, respectively. Graph representations of messages outperformed simpler features with AUCs: 0.837, 0.914, 0.846, 0.884 for informational, medical, social, and logistical communication, respectively. Representing words with Word2Vec embeddings, and mapping features using a CNN had the best performance with AUCs: 0.908 for informational, 0.917 for medical, 0.935 for social, and 0.943 for logistical categories.

Discussion And Conclusion: Word2Vec and graph representations improved the accuracy of classifying portal messages compared to features that lacked semantic information such as bag of words, and bag of phrases. Furthermore, using Word2Vec along with a CNN model, which provide a higher order representation, improved the classification of portal messages.
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http://dx.doi.org/10.1016/j.jbi.2017.08.014DOI Listing
October 2017

Long-term Patterns of Patient Portal Use for Pediatric Patients at an Academic Medical Center.

Appl Clin Inform 2017 Aug 2;8(3):779-793. Epub 2017 Aug 2.

Bryan Steitz, 2525 West End Avenue, Suite 1475, Nashville, TN 37203, Tel. (502) 320-6797, Email:

Background: Patient portal adoption has increased over the last two decades. Most research about patient portals has focused on adult populations in the primary care and medical specialty settings.

Objective: We describe initial and long-term portal use by pediatric patients and their caregivers in a broadly deployed patient portal at an academic medical center.

Methods: We analyzed portal usage for pediatric patients and their caregivers from 2008 to 2014. We recorded usage events with time stamps; user role defined as self, surrogate (i.e., parent or guardian), or delegate; and functions accessed. Usage events were grouped into sessions to calculate descriptive statistics by patient age, user role, and active use over time.

Results: From 2008 to 2014, the number of portal accounts increased from 633 to 17,128. 15.9% of pediatric patients had their own account; 93.6%, a surrogate account; and 2.2% a delegate account. During the study period, 15,711 unique users initiated 493,753 sessions and accessed 1,491,237 functions. Most commonly used functions were secure messaging (accessed in 309,204 sessions; 62.6%); test results (174,239; 35.3%) and appointments (104,830; 21.2%). Function usage was greatest for patients ages 0-2 years (136,245 functions accessed; 23.1%) and 15-17 years (109,241;18.5%). Surrogate users conducted 83.2% of logins for adolescent patients. Portal accounts were actively used for < 1 year for 9,551 patients (55.8%), 1-2 years for 2,826 patients (16.5%), 2-3 years for 1,968 patients (11.5%) and over 3 years for 2,783 patients (16.3%).

Conclusion: Pediatric patients and caregivers have avidly used messaging, test result, and appointment functions. The majority of access was done by surrogates. Adolescent portal usage increased with age. Most accounts for pediatric patients were only used actively for a few years, with peak usage for patients in early childhood and late adolescence.
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http://dx.doi.org/10.4338/ACI-2017-01-RA-0005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6220688PMC
August 2017

A comparison of rule-based and machine learning approaches for classifying patient portal messages.

Int J Med Inform 2017 09 23;105:110-120. Epub 2017 Jun 23.

Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.

Objective: Secure messaging through patient portals is an increasingly popular way that consumers interact with healthcare providers. The increasing burden of secure messaging can affect clinic staffing and workflows. Manual management of portal messages is costly and time consuming. Automated classification of portal messages could potentially expedite message triage and delivery of care.

Materials And Methods: We developed automated patient portal message classifiers with rule-based and machine learning techniques using bag of words and natural language processing (NLP) approaches. To evaluate classifier performance, we used a gold standard of 3253 portal messages manually categorized using a taxonomy of communication types (i.e., main categories of informational, medical, logistical, social, and other communications, and subcategories including prescriptions, appointments, problems, tests, follow-up, contact information, and acknowledgement). We evaluated our classifiers' accuracies in identifying individual communication types within portal messages with area under the receiver-operator curve (AUC). Portal messages often contain more than one type of communication. To predict all communication types within single messages, we used the Jaccard Index. We extracted the variables of importance for the random forest classifiers.

Results: The best performing approaches to classification for the major communication types were: logistic regression for medical communications (AUC: 0.899); basic (rule-based) for informational communications (AUC: 0.842); and random forests for social communications and logistical communications (AUCs: 0.875 and 0.925, respectively). The best performing classification approach of classifiers for individual communication subtypes was random forests for Logistical-Contact Information (AUC: 0.963). The Jaccard Indices by approach were: basic classifier, Jaccard Index: 0.674; Naïve Bayes, Jaccard Index: 0.799; random forests, Jaccard Index: 0.859; and logistic regression, Jaccard Index: 0.861. For medical communications, the most predictive variables were NLP concepts (e.g., Temporal_Concept, which maps to 'morning', 'evening' and Idea_or_Concept which maps to 'appointment' and 'refill'). For logistical communications, the most predictive variables contained similar numbers of NLP variables and words (e.g., Telephone mapping to 'phone', 'insurance'). For social and informational communications, the most predictive variables were words (e.g., social: 'thanks', 'much', informational: 'question', 'mean').

Conclusions: This study applies automated classification methods to the content of patient portal messages and evaluates the application of NLP techniques on consumer communications in patient portal messages. We demonstrated that random forest and logistic regression approaches accurately classified the content of portal messages, although the best approach to classification varied by communication type. Words were the most predictive variables for classification of most communication types, although NLP variables were most predictive for medical communication types. As adoption of patient portals increases, automated techniques could assist in understanding and managing growing volumes of messages. Further work is needed to improve classification performance to potentially support message triage and answering.
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http://dx.doi.org/10.1016/j.ijmedinf.2017.06.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5546247PMC
September 2017

Influence of Human Leukocyte Antigen (HLA) Alleles and Killer Cell Immunoglobulin-Like Receptors (KIR) Types on Heparin-Induced Thrombocytopenia (HIT).

Pharmacotherapy 2017 Sep 4;37(9):1164-1171. Epub 2017 Sep 4.

Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.

Heparin-induced thrombocytopenia (HIT) is an unpredictable, life-threatening, immune-mediated reaction to heparin. Variation in human leukocyte antigen (HLA) genes is now used to prevent immune-mediated adverse drug reactions. Combinations of HLA alleles and killer cell immunoglobulin-like receptors (KIR) are associated with multiple autoimmune diseases and infections. The objective of this study is to evaluate the association of HLA alleles and KIR types, alone or in the presence of different HLA ligands, with HIT. HIT cases and heparin-exposed controls were identified in BioVU, an electronic health record coupled to a DNA biobank. HLA sequencing and KIR type imputation using Illumina OMNI-Quad data were performed. Odds ratios for HLA alleles and KIR types and HLA*KIR interactions using conditional logistic regressions were determined in the overall population and by race/ethnicity. Analysis was restricted to KIR types and HLA alleles with a frequency greater than 0.01. The p values for HLA and KIR association were corrected by using a false discovery rate q<0.05 and HLA*KIR interactions were considered significant at p<0.05. Sixty-five HIT cases and 350 matched controls were identified. No statistical differences in baseline characteristics were observed between cases and controls. The HLA-DRB3*01:01 allele was significantly associated with HIT in the overall population (odds ratio 2.81 [1.57-5.02], p=2.1×10 , q=0.02) and in individuals with European ancestry, independent of other alleles. No KIR types were associated with HIT, although a significant interaction was observed between KIR2DS5 and the HLA-C1 KIR binding group (p=0.03). The HLA-DRB3*01:01 allele was identified as a potential risk factor for HIT. This class II HLA gene and allele represent biologically plausible candidates for influencing HIT pathogenesis. We found limited evidence of the role of KIR types in HIT pathogenesis. Replication and further study of the HLA-DRB3*01:01 association is necessary.
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http://dx.doi.org/10.1002/phar.1983DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5600645PMC
September 2017

Improving Medication Adherence with Two-way Short Message Service Reminders in Sickle Cell Disease and Asthma. A feasibility randomized controlled trial.

Appl Clin Inform 2017 05 24;8(2):541-559. Epub 2017 May 24.

Robert M. Cronin, Department of Biomedical Informatics, Vanderbilt University Medical Center, 2525 West End Suite 1475, Nashville, TN 37203, USA, Email: [email protected] vanderbilt.edu.

Introduction: Sickle cell disease (SCD) is a childhood and adult disease that primarily affects African Americans, characterized by life threatening sequelae mitigated by medications. One-way and two-way short message service (SMS) medication reminders have differing efficacy in chronic diseases. There is limited literature about SMS medication reminders in SCD.

Objective: The goal of this study was to test the feasibility, defined by recruitment/acceptance, retention/attrition, and technology utilization, of two-way SMS medication reminders in individuals with SCD with and without asthma.

Materials And Methods: Participants were randomly allocated to standard care or reminders. Two-way SMS reminders were automated using Research Electronic Data Capture (REDCap) for hydroxyurea, fluticasone, budesonide and montelukast. Adherence was measured using the Morisky Medication Adherence Scale-8 (MMAS-8). Asthma control was assessed using the Childhood and Adult-Asthma Control Tests (ACT). Participants were enrolled 28 to 60 days with a common termination date.

Results: The recruitment rate was 95% (47/49) and 82.9% completed the study. Among the 47 study participants enrolled, 51.1% were male, 61.7% were adults, median age was 20 (range: 3 to 59), and 98% were African Americans. Of the 26 participants receiving messages, 20% responded on over 95% of the days and usage varied with an average response rate of 33%, ranging from 21% to 46%. Medication adherence scores improved significantly in the intervention group (3.42 before, 5.46 after; p=0.002), but not in the control group (3.90 before, 4.75 after; p=0.080). Childhood-ACT scores improved in the intervention group (19.20 before, 24.25 after). Adult-ACT scores within the intervention arm were unchanged (21.0 before, 22.0 after. ACT scores did not improve significantly.

Conclusion: This study demonstrated the feasibility for two-way SMS medication reminders to improve medication adherence in a high-risk population where daily medication adherence is critical to health outcomes and quality of life.
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http://dx.doi.org/10.4338/ACI-2016-12-RA-0203DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6241750PMC
May 2017

Use of a Patient Portal During Hospital Admissions to Surgical Services.

AMIA Annu Symp Proc 2016 10;2016:1967-1976. Epub 2017 Feb 10.

Vanderbilt University Medical Center, Nashville, TN.

Patient portal research has focused on medical outpatient settings, with little known about portal use during hospitalizations or by surgical patients. We measured portal adoption among patients admitted to surgical services over two years. Surgical services managed 37,025 admissions of 31,310 unique patients. One-fourth of admissions (9,362, 25.3%) involved patients registered for the portal. Registration rates were highest for admissions to laparoscopic/gastrointestinal (55%) and oncology/endocrine (50%) services. Portal use occurred during 1,486 surgical admissions, 4% of all and 16% of those registered at admission. Inpatient portal use was associated with patients who were white, male, and had longer lengths of stay (p < 0.01). Viewing health record data and secure messaging were the most commonly used functions, accessed in 4,836 (72.9%) and 1,626 (24.5%) user sessions. Without specific encouragement, hospitalized surgical patients are using our patient portal. The surgical inpatient setting may provide opportunities for patient engagement using patient portals.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5333326PMC
September 2017

Adoption of Secure Messaging in a Patient Portal across Pediatric Specialties.

AMIA Annu Symp Proc 2016 10;2016:1930-1939. Epub 2017 Feb 10.

Vanderbilt University Medical Center, Nashville, TN.

Few studies have explored adoption of patient portals for pediatric patients outside primary care or disease-specific applications. We examined use of patient-provider messaging in a patient portal across pediatric specialties during the three years after implementation of pediatric portal accounts at Vanderbilt University Medical Center. We determined the number of patient-initiated message threads and clinic visits for pediatric specialties and percentage of these outpatient interactions (i.e., message threads + clinic visits) done through messaging. Generalized estimating equations measured the likelihood of message-based interaction. During the study period, pediatric families initiated 33,503 messages and participated in 318,386 clinic visits. The number of messages sent (and messaging percentage of outpatient interaction) increased each year from 2,860 (2.7%) to 18,772 (17%). Primary care received 4,368 messages (3.4% of outpatient interactions); pediatric subspecialties, 29,135 (13.0%). Rapid growth in messaging volume over time was seen in primary care and most pediatric specialties (OR>1.0; p<0.05).
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5333207PMC
September 2017

Evaluating electronic health record data sources and algorithmic approaches to identify hypertensive individuals.

J Am Med Inform Assoc 2017 01 7;24(1):162-171. Epub 2016 Aug 7.

Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA

Objective: Phenotyping algorithms applied to electronic health record (EHR) data enable investigators to identify large cohorts for clinical and genomic research. Algorithm development is often iterative, depends on fallible investigator intuition, and is time- and labor-intensive. We developed and evaluated 4 types of phenotyping algorithms and categories of EHR information to identify hypertensive individuals and controls and provide a portable module for implementation at other sites.

Materials And Methods: We reviewed the EHRs of 631 individuals followed at Vanderbilt for hypertension status. We developed features and phenotyping algorithms of increasing complexity. Input categories included International Classification of Diseases, Ninth Revision (ICD9) codes, medications, vital signs, narrative-text search results, and Unified Medical Language System (UMLS) concepts extracted using natural language processing (NLP). We developed a module and tested portability by replicating 10 of the best-performing algorithms at the Marshfield Clinic.

Results: Random forests using billing codes, medications, vitals, and concepts had the best performance with a median area under the receiver operator characteristic curve (AUC) of 0.976. Normalized sums of all 4 categories also performed well (0.959 AUC). The best non-NLP algorithm combined normalized ICD9 codes, medications, and blood pressure readings with a median AUC of 0.948. Blood pressure cutoffs or ICD9 code counts alone had AUCs of 0.854 and 0.908, respectively. Marshfield Clinic results were similar.

Conclusion: This work shows that billing codes or blood pressure readings alone yield good hypertension classification performance. However, even simple combinations of input categories improve performance. The most complex algorithms classified hypertension with excellent recall and precision.
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http://dx.doi.org/10.1093/jamia/ocw071DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5201185PMC
January 2017

Combining billing codes, clinical notes, and medications from electronic health records provides superior phenotyping performance.

J Am Med Inform Assoc 2016 Apr 2;23(e1):e20-7. Epub 2015 Sep 2.

Department of Biomedical Informatics, Vanderbilt University, Nashville, TN, USA Department of Medicine, Vanderbilt University, Nashville, TN, USA

Objective: To evaluate the phenotyping performance of three major electronic health record (EHR) components: International Classification of Disease (ICD) diagnosis codes, primary notes, and specific medications.

Materials And Methods: We conducted the evaluation using de-identified Vanderbilt EHR data. We preselected ten diseases: atrial fibrillation, Alzheimer's disease, breast cancer, gout, human immunodeficiency virus infection, multiple sclerosis, Parkinson's disease, rheumatoid arthritis, and types 1 and 2 diabetes mellitus. For each disease, patients were classified into seven categories based on the presence of evidence in diagnosis codes, primary notes, and specific medications. Twenty-five patients per disease category (a total number of 175 patients for each disease, 1750 patients for all ten diseases) were randomly selected for manual chart review. Review results were used to estimate the positive predictive value (PPV), sensitivity, andF-score for each EHR component alone and in combination.

Results: The PPVs of single components were inconsistent and inadequate for accurately phenotyping (0.06-0.71). Using two or more ICD codes improved the average PPV to 0.84. We observed a more stable and higher accuracy when using at least two components (mean ± standard deviation: 0.91 ± 0.08). Primary notes offered the best sensitivity (0.77). The sensitivity of ICD codes was 0.67. Again, two or more components provided a reasonably high and stable sensitivity (0.59 ± 0.16). Overall, the best performance (Fscore: 0.70 ± 0.12) was achieved by using two or more components. Although the overall performance of using ICD codes (0.67 ± 0.14) was only slightly lower than using two or more components, its PPV (0.71 ± 0.13) is substantially worse (0.91 ± 0.08).

Conclusion: Multiple EHR components provide a more consistent and higher performance than a single one for the selected phenotypes. We suggest considering multiple EHR components for future phenotyping design in order to obtain an ideal result.
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http://dx.doi.org/10.1093/jamia/ocv130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4954637PMC
April 2016

Rapid growth in surgeons' use of secure messaging in a patient portal.

Surg Endosc 2016 Apr 27;30(4):1432-40. Epub 2015 Jun 27.

Department of Biomedical Informatics, Vanderbilt University, Nashville, TN, USA.

Background: Use of secure messaging through patient portals has risen substantially in recent years due to provider incentives and consumer demand. Secure messaging may increase patient satisfaction and improve outcomes, but also adds to physician workload. Most prior studies of secure messaging focused on primary care and medical specialties. We examined surgeons' use of secure messaging and the contribution of messaging to outpatient interactions in a broadly deployed patient portal.

Methods: We determined the number of clinic visits and secure messages for surgical providers in the first 3 years (2008-2010) after patient portal deployment at an academic medical center. We calculated the proportion of outpatient interaction conducted through messaging for each specialty. Logistic regression models compared the likelihood of message-based versus clinic outpatient interaction across surgical specialties.

Results: Over the study period, surgical providers delivered care in 648,200 clinic visits and received 83,912 messages, with more than 200% growth in monthly message volume. Surgical specialties receiving the most messages were orthopedics/podiatry (25.1%), otolaryngology (20.1%), urology (10.8%), and general surgery (9.6%); vascular surgery (0.8%) and pediatric general surgery (0.2%) received the fewest. The proportion of outpatient interactions conducted through secure messaging increased significantly from 5.4% in 2008 to 15.3% in 2010 (p < 0.001) with all specialties experiencing growth. Heart/lung transplantation (74.9%), liver/kidney/pancreas transplantation (69.5%), and general surgery (48.7%) had the highest proportion of message-based outpatient interaction by the end of the study.

Conclusions: This study demonstrates rapid adoption of online secure messaging across surgical specialties with significant growth in its use for outpatient interaction. Some specialties, particularly those with long-term follow-up, interacted with patients more through secure messaging than in person. As surgeons devote more time to secure messaging, additional research will be needed to understand the care delivered through online interactions and to develop models for reimbursement.
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http://dx.doi.org/10.1007/s00464-015-4347-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4881849PMC
April 2016
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